vital signs

Question 1

what are your 5 measurements when taking vital signs

Answer 1

temp, pulse, BP, resp. rate, O2 saturation

Question 2

when do you measure vital signs?

Answer 2

Admission, per physician order, any changes in patients condition, before major procedures, during blood transfusion, after meds that affect vital signs

Question 3

normal oral/tympanic/temporal temp range

Answer 3

97.6-99.6

Question 4

normal rectal temp range

Answer 4

98.6-100.4

Question 5

normal axilla temp range

Answer 5

96.6-98.6

Question 6

normal pulse range

Answer 6

60-100 BPM

Question 7

normal respiration range

Answer 7

12-20 BPM

Question 8

normal BP

Answer 8

less than 120/80 mmHg

Question 9

pre-hypertensive BP range

Answer 9

sys.: 120-139 dia.:80-89

Question 10

hypertensive BP range

Answer 10

Sys. greater than 140 dia. greater than 9-

Question 11

hypotensive BP range

Answer 11

sys. less than 90 and symptomatic

Question 12

what are the 2 things body temp. shows

Answer 12

heat produced and heat lost

Question 13

acceptable temp. range

Answer 13

96.8-100.4

Question 14

radiation

Answer 14

transfer of heat from surface of one object to another without direct contact

Question 15

conduction

Answer 15

transfer of heat from one object to another with direct contact

Question 16

convection

Answer 16

transfer of hat away by air movement

Question 17

evaporation

Answer 17

transfer of heat energy when a liquid is changed to a gas

Question 18

diaphoresis

Answer 18

visible perspiration

Question 19

6 factors affecting body temp

Answer 19

age, hormonal level, environment, exercise, circadian rhythm, temperature alterations

Question 20

pyrexia

Answer 20

fever

Question 21

when is pyrexia harmful

Answer 21

above 102.2

Question 22

what increases when someone has a fever ( 4 things )

Answer 22

metabolism, oxygen consumption, heart rate, respiratory rate

Question 23

hyperthermia

Answer 23

inability to promote heat loss or reduce production

Question 24

heatstroke

Answer 24

body temp 104 or more

Question 25

heatstroke signs and symptoms

Answer 25

DRY, HOT SKIN, confusion, excess thirst, muscle cramps, increased HR, decreased BP, no sweating

Question 26

heat exhaustion

Answer 26

diaphoresis resulting is excess water and electrolyte loss, body needs to replace

Question 27

hypothermia

Answer 27

prolonged exposure to cold which decreases body's ability to produce heat, temps less than 86 ranging to 96.8

Question 28

fahrenheit to celsius conversion

Answer 28

C= (F-32) x 5/9

Question 29

celsius to fahrenheit conversion

Answer 29

F= (9/5 x C) +32

Question 30

oral temperature is approx. ___ degree lower than core temp

Answer 30

1

Question 31

adult rectal temp. placement

Answer 31

1.5 in

Question 32

child rectal temp. placement

Answer 32

1 in

Question 33

infant rectal temp. placement

Answer 33

.5 in

Question 34

You have delegated vital signs to the nursing assistant. She tells you that the patient has just finished a cup of hot coffee. The nurse’s most appropriate advice would be to A. take the oral temperature as planned B. take a rectal temperature. C. wait 30 minutes and take an oral temperature. D. advise the patient to drink a glass of cold water.

Answer 34

C

Question 35

what do you do for a fever?

Answer 35

Obtain blood cultures if ordered, Monitor VS, assess skin color, temperature, turgor and lab work, Reduce frequency of activities to ↓ 02 demand, Maximize heat loss , Extra fluids, Tepid water bath, Oral hygiene, Dry bed linens, Antipyretic meds as ordered

Question 36

pulse

Answer 36

palpable bounding of blood flow noted at various points of the body

Question 37

what is the pulse showing

Answer 37

an indirect measure of circulatory status

Question 38

what do you do if you get a abnormal radial pulse?

Answer 38

obtain an apical pulse

Question 39

why do you check pulse on both wrists at the same time

Answer 39

to assess for abnormal rhythm or strength on one or both sides

Question 40

what is considered a normal pulse rhythm

Answer 40

2+

Question 41

what is gas exchange

Answer 41

the process of transporting oxygen into cells and carbon dioxide out of cells

Question 42

what are the 3 catagories of oxygenation?

Answer 42

ventilation, transport, perfusion

Question 43

impaired gas exchange

Answer 43

diffusion of gases becomes impaired

Question 44

ventilation

Answer 44

movement of gases into and out of the lung

Question 45

diffusion

Answer 45

movement of oxygen and carbon dioxide between alveoli and red blood cells

Question 46

perfusion

Answer 46

distribution of red blood cells to and from the pulmonary capillaries

Question 47

rate of respirations

Answer 47

haw many breaths per min.

Question 48

rhythm of respirations

Answer 48

regular or irregular

Question 49

depth of respirations

Answer 49

deep, normal, or shallow

Question 50

eupnea

Answer 50

ventilation of normal rate and depth

Question 51

bradypnea

Answer 51

slow breaths with normal depth <10 BPM

Question 52

tachypnea

Answer 52

rapid, shallow breathing >24 BPM

Question 53

apnea

Answer 53

pauses in breathing

Question 54

cheyne-stokes

Answer 54

rate and depth of breathing increase until apnea

Question 55

biots respiration

Answer 55

normal breathing followed by a period of apnea

Question 56

acceptable SpO2 range

Answer 56

95%-100%

Question 57

what is BP

Answer 57

force exerted against the blood vessels by the blood

Question 58

what do you measure BP in

Answer 58

millimeters of mercury

Question 59

Hypotension symptoms

Answer 59

skin mottling, clamminess, confusion, high HR, low urine output

Question 60

P in PQRST

Answer 60

provokes/palliates

Question 61

R in PQRST

Answer 61

quality

Question 62

R in PQRST

Answer 62

region/radiation

Question 63

S in PQRST

Answer 63

Severity and setting

Question 64

T in PQRST

Answer 64

timing